Medicare Part D (Federal Prescription Drug Benefit) FAQs

Effective January 1, 2022, many pharmacy services, including covered outpatient drugs, enteral nutrition, some medical supplies and the applicable administrative services (for example, claim submission, processing, appeals, authorization, etc.) related to pharmacy claims, transition to Medi-Cal Rx. Pharmacy providers should submit claims for these products to Medi-Cal Rx. For more information on services covered by Medi-Cal Rx, providers should refer to the Medi-Cal Rx website.

1. How does Medicare Part D affect pharmacists?

Medicare Part D chiefly affects the way pharmacists get paid when dispensing drugs to Medicare/Medi-Cal dual-eligible recipients and all other Part D eligible recipients. Beginning January 1, 2006, most outpatient drug claims and some medical supply claims used in the administration of insulin (like insulin syringes), will be submitted to and paid by the recipient’s Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug (MAPD) Plan. Most pharmacy claims submitted to Medi-Cal for dates of service on or after January 1, 2006 will be denied.

2. How do I know which plan the recipient uses?

The recipient should have either a PDP or MAPD card, much like the Medi-Cal Benefit Identification Card (BIC). That card will contain information needed to bill the drug plan. If the recipient does not have a PDP or MAPD card, run the recipient’s BIC through the Medi-Cal eligibility system. The eligibility system may show information about the plan the recipient has chosen.

Additionally, NDCHealth is contracted with the Centers for Medicare & Medicaid Services (CMS) for Eligibility Facilitator Services. They will provide real-time insurance coverage information to pharmacies to give them the ability to submit claims to the right PDP and any supplemental plans in the correct order.
For more information, visit the NDCHealth Web site.

3. I heard Medi-Cal will still pay for some drugs. What drugs are paid for, and under what conditions?

Even though there are nine categories of drugs excluded from coverage under Part D, drug plans have the option of covering drugs within those categories. Medi-Cal will continue to pay providers’ claims for the six “Part D excluded” categories of drugs that it currently covers. The categories that Medi-Cal will continue to cover are:

  • Anorexia, weight loss or weight gain

  • Symptomatic relief of coughs and colds

  • Non-prescription drugs (Part D, not Medi-Cal, covers insulin products)

  • Barbiturates

  • Benzodiazepines

  • Prescription vitamins and minerals (Select single vitamins and minerals pursuant to prior authorization or utilization restrictions. Combination vitamin and mineral products are not a benefit. Vitamins or minerals used for dietary supplementation are not a benefit.)
4. The recipient owes a co-pay but won’t pay. What can I do?

Medicare Part D eligible recipients must make co-payments when they purchase drugs. Pharmacists may choose to waive co-pays or deny service if a recipient cannot pay the co-pay.

5. How can I find more information?

For more information review the following:

Outside Resources

Download PDF (Portable Document Format) reader from the Web Tool Box.